Ashley Lodge Nursing Home, OSV 0000009, 05 December 2017

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Centre name: Ashley Lodge Nursing Home

Centre ID: OSV-0000009

Centre address:

Tully East, Kildare, Kildare.

Telephone number: 045 521 300

Email address: ashleylodgenursinghome@yahoo.ie

Type of centre: A Nursing Home as per Health (Nursing Homes) Act 1990

Registered provider: Ashley Lodge Nursing Home Limited

Provider Nominee: Claire Welford

Lead inspector: Sheila Doyle

Support inspector(s): Breeda Desmond

Type of inspection Unannounced

Number of residents on the

date of inspection: 41

Number of vacancies on the

date of inspection: 14

Health Information and Quality Authority

Regulation Directorate

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About monitoring of compliance

The purpose of regulation in relation to designated centres is to safeguard vulnerable people of any age who are receiving residential care services. Regulation provides assurance to the public that people living in a designated centre are receiving a service that meets the requirements of quality standards which are underpinned by regulations. This process also seeks to ensure that the health, wellbeing and quality of life of people in residential care is promoted and protected. Regulation also has an important role in driving continuous improvement so that residents have better, safer lives.

The Health Information and Quality Authority has, among its functions under law, responsibility to regulate the quality of service provided in designated centres for children, dependent people and people with disabilities.

Regulation has two aspects:

▪ Registration: under Section 46(1) of the Health Act 2007 any person carrying on the business of a designated centre can only do so if the centre is registered under this Act and the person is its registered provider.

▪ Monitoring of compliance: the purpose of monitoring is to gather evidence on which to make judgments about the ongoing fitness of the registered provider and the provider’s compliance with the requirements and conditions of his/her registration.

Monitoring inspections take place to assess continuing compliance with the

regulations and standards. They can be announced or unannounced, at any time of day or night, and take place:

▪ to monitor compliance with regulations and standards

▪ to carry out thematic inspections in respect of specific outcomes

▪ following a change in circumstances; for example, following a notification to the Health Information and Quality Authority’s Regulation Directorate that a provider has appointed a new person in charge

▪ arising from a number of events including information affecting the safety or wellbeing of residents.

The findings of all monitoring inspections are set out under a maximum of 18

outcome statements. The outcomes inspected against are dependent on the purpose of the inspection. In contrast, thematic inspections focus in detail on one or more outcomes. This focused approach facilitates services to continuously improve and achieve improved outcomes for residents of designated centres.

Please note the definition of the following term used in reports:

responsive behaviour (how people with dementia or other conditions may

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Compliance with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013, Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 and the National Standards for Residential Care Settings for Older People in Ireland.

This inspection report sets out the findings of a monitoring inspection, the purpose of which was to monitor ongoing regulatory compliance. This monitoring inspection was un-announced and took place over 1 day(s).

The inspection took place over the following dates and times

From: To:

05 December 2017 10:00 05 December 2017 16:00

The table below sets out the outcomes that were inspected against on this inspection.

Outcome Our Judgment

Outcome 01: Statement of Purpose Substantially Compliant Outcome 02: Governance and Management Non Compliant - Moderate Outcome 04: Suitable Person in Charge Compliant

Outcome 05: Documentation to be kept at a

designated centre Compliant

Outcome 08: Health and Safety and Risk

Management Non Compliant - Moderate

Outcome 15: Food and Nutrition Compliant Outcome 16: Residents' Rights, Dignity and

Consultation Compliant

Outcome 18: Suitable Staffing Non Compliant - Moderate

Summary of findings from this inspection

This was an unannounced follow-up inspection to review progress with actions identified from the previous inspection in September 2017.

Governance of the centre remained an issue. There had been several changes to management in recent months. The current person in charge worked between two centres and the provider representative worked among three centres.

The actions required from the previous inspection had been addressed although other issues were identified during this inspection. While improvements were noted, a full time person in charge was necessary to ensure effective oversight to deliver a safe, quality service to enable positive outcomes for residents. Systems to monitor the quality and safety of clinical care and the quality of life for residents had improved but required further attention to ensure that issues identified were actioned and followed up on, as part of their quality improvement cycle. This

included actions required in relation to infection control, health and safety and staff supervision.

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with the regulations. Care documentation relating to food and nutrition were in place in the sample of resident documentation reviewed which demonstrated a better oversight of residents’ needs and outcomes.

There was evidence to show that residents were protected and safeguarded. Inspectors observed that staff were respectful and kind in the way they spoke with residents, and offered and delivered assistance. Inspectors spoke with two relatives and four residents during the inspection who gave positive feedback to inspectors about the quality of care and quality of life in the centre.

The activities co-ordinator was recently appointed and full-time in post. Residents gave positive feedback and inspectors observed the enjoyment during the day-long activities during the inspection. Residents and relatives also highlighted the Saturday music sessions and the alternate Tuesday music sessions in addition to other

activities.

The Action Plan at the end of this report identifies improvements that must be made to meet the requirements of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 and the National Quality Standards for Residential Care Settings for Older People in Ireland 2016.

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Compliance with Section 41(1)(c) of the Health Act 2007 and with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013, Health Act 2007 (Registration of Designated Centres for Older People) Regulations 2015 and the National Standards for Residential Care Settings for Older People in Ireland.

Outcome 01: Statement of Purpose

There is a w ritten statement of purpose that accurately describes the service that is provided in the centre. The services and facilities outlined in the

Statement of Purpose, and the manner in w hich care is provided, reflect the diverse needs of residents.

Theme:

Governance, Leadership and Management

Outstanding requirement(s) from previous inspection(s):

No actions were required from the previous inspection.

Findings:

The statement of purpose did not contain the details as described in the regulations. The organisational structure and staff numbers did not reflect the existing

arrangements. In addition the conditions of registration were not included.

Judgment:

Substantially Compliant

Outcome 02: Governance and Management

The quality of care and experience of the residents are monitored and

developed on an ongoing basis. Effective management systems and sufficient resources are in place to ensure the delivery of safe, quality care services. There is a clearly defined management structure that identifies the lines of authority and accountability.

Theme:

Some action(s) required from the previous inspection were not satisfactorily implemented.

Findings:

While the management structure in place outlined the lines of authority and accountability, the registered provider had not ensured the designated centre had

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office of the Chief Inspector was not satisfied that this arrangement could assure effective governance, operational management and administration of the centre to enable a safe, appropriate and consistent service that was effectively monitored.

Inspectors saw that adequate supervision arrangements were not in place. This was noticeable as regards cleaning, hygiene, infection control and some risk issues which could have a negative impact on the overall safety of residents.

The provider representative outlined that annual review as described in regulation 23 was almost complete for 2017 and would be available to the chief inspector if required. Systems to monitor the quality and safety of clinical care and the quality of life for residents had improved but required further attention to ensure that issues identified were followed up on, as part of their quality improvement cycle. Audits were undertaken across a range of clinical areas but some did not inform practice and examples of this will be described under Outcome 8.

Judgment:

Non Compliant - Moderate

Outcome 04: Suitable Person in Charge

The designated centre is managed by a suitably qualified and experienced person w ith authority, accountability and responsibility for the provision of the service.

Theme:

Findings:

The person in charge was part-time in post; was suitable qualified and had the

necessary experience as required by the regulations. She demonstrated sufficient clinical knowledge and had sufficient knowledge of the legislation and her statutory

responsibilities. The assistant director of nursing was full-time in post in the centre and supported the person in charge in her duties.

Judgment:

Compliant

Outcome 05: Documentation to be kept at a designated centre

The records listed in Schedules 3 and 4 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 are maintained in a manner so as to ensure completeness, accuracy and ease of retrieval. The designated centre is adequately insured against

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all of the w ritten operational policies as required by Schedule 5 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013.

Theme:

The action(s) required from the previous inspection were satisfactorily implemented.

Findings:

Issues identified on the previous inspection were remedied. The inspector reviewed a sample of staff files, directory of residents and visitor’s sign-in book and they were compliant with the regulations.

Judgment:

Compliant

Outcome 08: Health and Safety and Risk Management

The health and safety of residents, visitors and staff is promoted and protected.

Theme:

Safe care and support

Findings:

Hygiene audits were completed as part of the system in place for monitoring the service's quality and safety, however, there was limited evidence that they were sufficiently robust. For example, several items were inappropriately stored on the floor of the hairdresser’s room, so effective cleaning could not be assured. Several hygiene practices observed on inspection were not in compliance with the national standards for infection prevention and control, which had the potential to negatively impact the safety and welfare of residents. For example, handling of unclean clothing and bed linen. In addition some areas of the centre looked visibly dirty.

The laundry was divided into two rooms which comprised the clean laundry room and the second, the dirty laundry room. While there were two sinks available here, neither was designated for hand washing.

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wing and this was quite small and possibly difficult to interpret by residents and visitors.

There were several storage rooms available which contained items such as clinical waste, hazardous solutions and clinical supplies. Some rooms were not locked enabling free access which would have a potentially harmful outcome for residents. Inspectors observed that cleaning trolleys were left unattended at times as well although this had previously been identified as a possible risk to residents.

Judgment:

Non Compliant - Moderate

Outcome 15: Food and Nutrition

Each resident is provided w ith food and drink at times and in quantities adequate for his/ her needs. Food is properly prepared, cooked and served, and is w holesome and nutritious. Assistance is offered to residents in a discrete and sensitive manner.

Theme:

Person-centred care and support

Findings:

The action from the previous inspection was remedied whereby appropriate records were maintained regarding residents’ food and nutrition to ensure they received adequate food and fluids throughout the day to prevent dehydration and malnutrition. Mealtime and snack times were observed during the inspection and residents and relatives gave positive feedback on their dining experience. Meals presented were attractively presented and appetising and staff assisted people with their meals in a respectful and dignified manner. There were two main dining rooms and another lounge that residents used for their meals. Residents had timely access to allied health

professionals and diets were modified in accordance with residents’ assessed needs.

Judgment:

Compliant

Outcome 16: Residents' Rights, Dignity and Consultation

Residents are consulted w ith and participate in the organisation of the centre. Each resident’s privacy and dignity is respected, including receiving visitors in private. He/ she is facilitated to communicate and enabled to exercise choice and control over his/ her life and to maximise his/ her

independence. Each resident has opportunities to participate in meaningful activities, appropriate to his or her interests and preferences.

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Person-centred care and support

Findings:

The last inspection identified that action was necessary regarding opportunities for residents to participate in activities in accordance with their interests and capacities. This was remedied whereby a new activities co-ordinator was appointed and worked full time in the centre. Residents gave positive feedback about the range of activities, their choice of whether to participate or not and the ‘wonderful’ ideas for activities. Inspectors observed the enjoyment, interaction and gentle encouragement during the daylong activities.

Judgment:

Compliant

Outcome 18: Suitable Staffing

There are appropriate staff numbers and skill mix to meet the assessed needs of residents, and to the size and layout of the designated centre. Staff have up-to-date mandatory training and access to education and training to meet the needs of residents. All staff and volunteers are supervised on an

appropriate basis, and recruited, selected and vetted in accordance w ith best recruitment practice. The documents listed in Schedule 2 of the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 are held in respect of each staff member.

Theme:

Workforce

Findings:

Staff records demonstrated that staff had access to training and development in accordance with their roles and responsibilities. The provider representative outlined that interviews had taken place for additional staff and there were recruitment advertisements in the local media for staff. However, staff were not supervised appropriate to their role and responsibilities, so positive outcomes for residents could not be assured, as described previously in the report.

Judgment:

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Closing the Visit

At the close of the inspection a feedback meeting was held to report on the inspection findings.

Acknowledgements

The inspector wishes to acknowledge the cooperation and assistance of all the people who participated in the inspection.

Report Compiled by:

Sheila Doyle

Inspector of Social Services Regulation Directorate

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Provider’s response to inspection report1

Centre name: Ashley Lodge Nursing Home

Centre ID: OSV-0000009

Date of inspection: 05/12/2017

Date of response: 21/12/2017

Requirements

This section sets out the actions that must be taken by the provider or person in charge to ensure compliance with the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2013 and the

National Quality Standards for Residential Care Settings for Older People in Ireland.

All registered providers should take note that failure to fulfil your legal obligations and/or failure to implement appropriate and timely action to address the non compliances identified in this action plan may result in enforcement action and/or prosecution, pursuant to the Health Act 2007, as amended, and

Regulations made thereunder.

Outcome 01: Statement of Purpose Theme:

The Registered Provider is failing to comply with a regulatory requirement in the following respect:

The governance structure and whole-time equivalent described did not reflect the new management structure identified during the inspection in September 2017.

1. Action Required:

Under Regulation 03(2) you are required to: Review and revise the statement of purpose at intervals of not less than one year.

1_{The Authority reserves the right to edit responses received for reasons including: clarity; completeness; and,}

compliance with legal norms.

Health Information and Quality Authority

Regulation Directorate

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Please state the actions you have taken or are planning to take:

The statement of purpose has been amended to reflect the WTE of the new

management structure. In addition a new statement of purpose will be written in 2018 in line with the new HIQA template and to reflect the new staffing arrangements.

Proposed Timescale: 31/01/2018

Outcome 02: Governance and Management Theme:

Systems to monitor the quality and safety of clinical care and the quality of life for residents had improved but required further attention to ensure that issues identified were followed up on to inform practice, as part of their quality improvement cycle.

Under Regulation 23(c) you are required to: Put in place management systems to ensure that the service provided is safe, appropriate, consistent and effectively monitored.

New Audits will commence in January 2018 and these are designed to meet the

regulations and inform the homes quality improvement plans. The Provider will ensure that the findings and recommendations from these audits are actioned in practice.

Proposed Timescale: Ongoing with commencement 01/01/18

Proposed Timescale: 01/01/2018 Theme:

While the management structure in place outlined the lines of authority and accountability, the registered provider had not ensured the designated centre had sufficient resources to ensure effective delivery of care in accordance with the

statement of purpose. The person in charge was person in charge for two designated centres. The office of the chief inspector was not satisfied that this arrangement could assure effective governance, operational management and administration of the centre to enable a safe, appropriate and consistent service that was effectively monitored.

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Under Regulation 23(c) you are required to: Put in place management systems to ensure that the service provided is safe, appropriate, consistent and effectively monitored.

A full time PIC and a new Assistant Director of Nursing have now been appointed. This new Governance structure will commence following induction (08th-21st. January) on the 22/01/18.

Outcome 08: Health and Safety and Risk Management Theme:

There were several storage rooms available which contained items such as clinical waste, hazardous solutions and clinical supplies, however, some were not locked enabling free access which would have a potentially harmful outcome for residents.

Cleaning trolleys which had chemicals on them, were left unattended at times.

Under Regulation 26(1)(d) you are required to: Ensure that the risk management policy set out in Schedule 5 includes arrangements for the identification, recording,

investigation and learning from serious incidents or adverse events involving residents.

All storage areas will have a mechanical key pad. These have been ordered from the UK and will be installed within 4 weeks. The cleaning trolleys have been made safer with a new storage box and the hospitality staff have been alerted to the risks on their trolleys and their requirement to keep same under supervision at all times. This is being

monitored daily by the ADON and the Nurse in Charge. A hospitality supervisor has been appointed.

Hygiene audits were not sufficiently robust.

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effective cleaning could not be assured.

Staff handling of unclean clothing and bed linen was not in compliance with the national standards for infection prevention and control which had the potential to negatively impact the safety and welfare of residents.

A sink for hand washing was not designated in the laundry room.

Under Regulation 27 you are required to: Ensure that procedures, consistent with the standards for the prevention and control of healthcare associated infections published by the Authority are implemented by staff.

The inappropriate storage in the hairdressers has now stopped and the items have been removed.

All staff have been re-alerted to the safe handling of linen and the national infection control principles. This is monitored daily by the ADON and Nurse in Charge.

The soap dispensar and the signage for the hand washing sink in the laundry have now been applied.

The Person in Charge (PIC) is failing to comply with a regulatory requirement in the following respect:

Several of the emergency exit signs were not working on the day of inspection.

Under Regulation 28(1)(b) you are required to: Provide adequate means of escape, including emergency lighting.

The quarterly fire maintenance was scheduled for the 15th. December 2017. This has now been completed and all emergency lights have now been repaired and the nurse in charge now checks these daily.

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in the following respect:

Procedures to be followed in the event of a fire were displayed in just one wing, this was quite small and possibly difficult to interpret by residents and visitors.

Under Regulation 28(3) you are required to: Display the procedures to be followed in the event of fire in a prominent place in the designated centre.

Enhanced emergency/fire notices are now displayed on all wings in addition to the PEEPS and the maps which are in each residents bedrooms.

Outcome 18: Suitable Staffing Theme:

Workforce

The Person in Charge (PIC) is failing to comply with a regulatory requirement in the following respect:

Staff were not supervised appropriate to their role and responsibilities.

Under Regulation 16(1)(b) you are required to: Ensure that staff are appropriately supervised.

A full time PIC and a new Assistant Director of Nursing have now been appointed. This new Governance structure will commence 22/01/18.